Deerstream

Student's Name	Peter Kenneth Ransom
Date Of Birth	12/25/2008
T shirt size	Adult Unisex S
PARENT INFORMATION
Parent 1	Ashley Ransom
Cell Phone	(919) 592-5557
Home/Work Phone	(919) 592-5557
Parent 2	Gifford Ransom
Cell Phone	(919) 594-9433
Home/Work Phone	(919) 594-9433
Emergency Contact 1	Ashley Ransom
Relationship	mother
Phone Number	(919) 592-5557
Emergency Contact 2	Giff Ransom
Relationship	father
Phone Number	(919) 594-9433
ALLERGY INFORMATION
Does this child have any known allergies?	No
OTHER MEDICAL INFORMATION
Physician's Name	Meri Harper
Physician's Phone Number	919-967-0771
Preferred Medical Facility	UNC
Current Medications and Dosages	none
Please list any significant medical information including chronic illnesses, injuries, physical limitations, and any diagnoses this child has received.	none
Will your child need the learning environment or assignments adapted in any way?	No
Insurance
Name of Policy Holder	Ashley Ransom
Employer	none
Insurance Company	cash pay
Policy Number	none
SIGNATURE	I, as parent or legal guardian, do hereby grant Deerstream faculty and trustees present the right to authorize emergency medical treatment for my child, named above, in the event that my designated representatie or I cannot be reached. I agree to hold harmless Deerstream and its agents from liability arising out of accident situations. The North Carolina Good Samaritan Law will apply.
Name	Ashley Ransom
Signature